Chronic Care Model

Theme: An organizational approach to caring for people with chronic disease in a primary care setting. The system is population-based and creates practical, supportive, evidenced-based interactions between an informed, activated patient and a prepared, proactive practice team. The Chronic Care Model emphases evidence-based, planned, integrated collaborative care.

Community Resources

• Community resources to support patient care are identified and made easily accessible.
• The health system coordinates planning with community service agencies and patients.

Health System Organization

• Organization goals for chronic illnesses are part of the annual business plan.
• Senior leadership is committed to meeting the needs of patients with chronic illness.
• The system pro-actively tries to impact the entire patient population with education and services.
• The system has adopted an effective performance improvement model.
• Provider incentives support chronic illness goals.

Self-Management Support

• Programs emphasize the patient's role in managing the illness.
• Educational resources increase patient knowledge, confidence, and skills.
• Patients are assisted in setting personal goals and are given a variety of other aids to assist in changing behavior.
• Mechanisms for patient peer support are accessible and the patient has access to behavior change programs.
• Measurement methods and feedback are provided to patients.
• Patients are assisted in improving communication with providers about their health care.

Decision Support

• Evidenced-based guidelines and protocols are integrated into the practice systems.
• The system integrates the clinical expertise from generalists and specialists.
• The specialist works to increase the expertise of the generalist.
• The entire care team works to maximize cooperation and the application of the best clinical expertise.

Delivery System Design

• The practice anticipates problems and provides services to maintain quality of life and function.
• The care team (primary care provider, care manager and specialist) works together with the patient.
• Specialty designed visits are scheduled with the practice team at regular intervals.
• The care team meets regularly to do population-based work.
• Systems are designed for regular communication and follow-up.

Clinical Information Systems

• A registry of patients with a chronic condition is maintained.
• A reminder system is used for both patients and the care team.
• The information system provides regular feedback to the care team.
• The system allows for care planning.

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